The Reporting of Adverse Health Events in Minnesota

1. The Reporting of Adverse Health Events in Minnesota MNASCA 2012 Annual Conference Diane Rydrych Minnesota Department of Health

2. Overview • Background on reporting system • Reporting requirements • Overall/ASC data • Case studies/discussion • Upcoming events • Discussion questions

3. Background • IOM report “To Err is Human” • 44,000 – 98,000 deaths/year • No one public “trigger” event that caused concern, but there were several media stories about errors • Formation of MAPS in 2000: MDH, MHA, MMA

4. Minnesota’s Reporting Law • Established in 2003 (ASC: 2004) • Hospitals, ASC’s, Boards • Annual report each January • Number of events by category at each facility • Outcome of event • Consumer companion report

5. Goals of the law • Not …to punish errors by health care practitioners or employees • Instead…to balance quality improvement and accountability for public health & safety • Focus on learning and transparency

6. MHA Advisory Groups Patients MDH Registry Calls to Action Sharing DB Safety alerts Administration Reporting Evaluation Outreach Goal setting Updates Trends Training QIO MAPS RCA review Regulators

7. What must be reported? • Any of the 28 events defined in law • Within 15 working days after discovery of the event • Within 60 days, findings of a root cause analysis and a corrective action plan • NO identifying information for any health professionals, employees or patients is included

8. Surgical/procedure Events Wrong surgery Retention of foreign object OR or Post-op death Product or Device Contaminated drugs or blood Air embolism Patient Protection Infant discharged to wrong person Patient elopement Care Management Medication error Maternal death Death from hypoglycemia Serious pressure ulcers Environmental Events Death from electric shock Wrong gas delivered Patient burns Patient falls Criminal Events Abduction Sexual assault Examples of reportable events(from list of 28 Serious Reportable Events created by NQF)

9. What must be reported? • RCA findings and corrective action • Why did the event happen? • What role did staffing, communication, training, etc play in the event? • What are you doing to keep it from happening again? • Time, location, injury • Event-specific questions

10. How does the system work? • Secure, web-based registry • Review of all RCA’s and corrective actions • Focus on learning and quality improvement • Trend analysis, safety alerts • Existing MDH regulatory responsibilities still in place

11. Adverse Events: 2003-2011

12. Adverse Events: 2011

13. ASC events

14. ASC events by type (all years)

15. ASC events

16. Patient Harm: ASC’s (all years)

17. 2012 Reportability Survey Patient entered the hospital as an outpatient for a dialysis fistula graft de-clotting procedure. The patient has a fistula graft in each arm, however the procedure was to be performed on the right arm. Prior to the procedure, the radiologist injected the local anesthetic into the left arm. The patient questioned the injection; the radiologist realized that the local anesthetic was injected in the incorrect side and proceeded to do a local injection on the right. The procedure continued as planned. Survey Results: • Reportable: 72% • Not Reportable: 26% • Need more information: 2%

18. 2012 Reportability Survey A cesarean section was planned for delivery of twins at 39 weeks along with a tubal ligation. Patient consented the day of surgery for cesarean section and tubal ligation. Complications occurred during the c-section. The twins were successfully delivered, however, the tubal ligation was not completed due to concerns about the mother’s health. Survey Results: • Not Reportable: 86% • Reportable: 10% • Need more information: 4%

19. 2012 Reportability Survey Patient underwent a breast biopsy under local anesthesia. An inspection of the needle immediately prior to the procedure showed that it was intact. During the procedure, a ~5 mm piece of the biopsy needle broke off under the skin.   This was discovered at the end of the procedure, while the patient was still in the procedure room. While an inspection of the needle immediately after the procedure clearly showed that a portion had broken off, the radiologist did not see a needle retained on x-ray. Survey Results: • Not Reportable: 76% • Reportable: 20% • Need more information: 4%

20. 2012 Reportability Survey Patient admitted to perioperative area for vaginal hysterectomy on same date. Foley urinary catheter and vaginal packing in place post-operatively. Patient admitted for overnight observation, with physicianorders for removal of foley urinary catheter and vaginal packing prior to discharge. Foley catheter removed but vaginal packing was not removed. Patient later reported to surgeon’s office during follow up call that she had removed the vaginal packing herself, at home on the day of discharge, when she noted difficulty voiding. Survey Results: • Reportable: 87% • Not Reportable: 13% • Need more information: 0%

21. 2012 Reportability Survey Patient seen in surgeon’s clinic for removal of cataract and replacement of lens. Patient and surgeon agreed that patient’s vision would not be corrected to 20/20 because patient had never had 20/20 vision and did not want this change. The patient consented to the correction of less than 20/20 and the surgery was scheduled. Physician ordered and implanted a lens that corrected vision to 20/20. After discussing with the surgeon, patient decided that he felt comfortable with the correction and did not want to have a second procedure. Survey Results: • Reportable: 65% • Not Reportable: 29% • Need more information: 6%

22. Key Findings • Problems are almost always at the system, not individual, level • Most adverse events happen because of breakdowns in: • Communication • Policies/Procedures • New challenges related to EHR’s, focus on costs, health reform, etc

23. Key Findings • Focusing on the causes of events is the only way to prevent their reoccurrence • Sharing information/best practices works • Need to create a culture of learning and accountability: • Speak up about unsafe situations • Be accountable for following safe practices

24. Still room to grow…. • Facilities still need support in getting “deep” enough in their analysis • 5 Why’s • Measurement of corrective actions continues to be a challenge • Hierarchy of corrective actions

25. 2012 Priorities • Time Out Campaign • Procedural areas • Leadership Engagement • Organizational Culture

26. Upcoming Events • May 2: statewide conference call • Early May: MDH Patient Safety mini-grants • May 31: RCA training, Duluth

27. Questions • What are the biggest patient safety issues in your facility? • How can we support your work?

28. www.health.state.mn.us/patientsafety Diane Rydrych Minnesota Department of Health 651-201-3564 diane.rydrych@state.mn.us For More Information: